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Full text of "United States Navy Medical News Letter Vol. 25, No. 3, 4 February 1955"

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UNITED STATES NAVY 

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Editor - Captain L. B. Marshall, MC, USN (RET) 



25 Friday, 4 February 1955 No. 3 



TABLE OF CONTENTS 

Opportunity for Residency Training in the Navy 2 

Clinical Syndrome of Acute Renal Insufficiency 3 

Ballistocardiography < . . . 6 

New Horizons in Cancer p g 

Infectious Hepatitis in Pregnant Women 10 

Infectious and Serum Hepatitis n 

Management of the Tuberculous Hip Joint j 2 

Surgical Treatment of Polycystic Kidney 14 

The Painful and Stiff Shoulder ^ 

Public Health Aspects of Periodontics jo 

Radioactive Isotopes 21 

Change of Address , 24 

Safe Practices for Navy Motor Vehicle Operators 25 

Medical Care of Atomic Casualties 29 

Medical Deep Sea Diving and Submarine Medicine Technicians 30 

Postg raduate Short Courses . 30 

Status of Allotment, reporting reservations on(BuMed Notice 7303} .... 31 

Cancer Education Program (SecNav Notice 6300) 31 

Immunization Certificate (BuMed Inst. 6230. 1 , Sup 1) 32 

PREVENTIVE MEDICINE SECTION 

Occurrence of Influenza 32 

Influenza Vaccines in Great Britain ,34 

Photofluorographic Detection of Cardiovascular Disease 34 

Vector Control by PMU No. 1 3^ 

Synthetic Cream Pastry Fillings 39 



* * * * * * 



2 



Medical News Letter, Vol. 25, No. 3 



Folic y 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

****** 
Notice 



Due to the critical shortage of medical officers, the Chief, Bureau of 
Medicine and Surgery, has recommended, and the Chief of Naval Personnel 
has concurred, that Reserve medical officers now on active duty who desire 
to submit requests for extension of their active duty for a period of three 
months or more will be given favorable consideration 

****** 
Op portunity for Residency Training in the Navy 

Applications for residency training are requested from Regular 
officers and those Reserve officers who have completed their obligated 
service under the Universal Military Training and Service Act, as amended. 

Training is available for Regular officers in all of the major medical 
specialties. It is available for Reserve officers in Pathology, Orthopedic 
Surgery, Obstetrics and Gynecology, Pediatrics, and Urology. There are 
a few billets available for training in civilian hospitals in the specialties 
of Anesthesiology, Otolaryngology, Dermatology and Syphilology. 

Residency training may be started immediately on completion of 
internship. It is now the desire of the Bureau of Medicine and Surgery 
to continue a resident in training without interruption until he has com- 
pleted the formal training requirements leading to certification by an 
American Specialty Board. The procedure will be strictly adhered to in 
every case where the demands of the service permit and providing the 
trainee shows satisfactory progres s. (ProfDiv, BuMed) 



****** 



Medical News Letter, Vol. 25, No. 3 
Clinical Syndrome of Acute Renal Insufficiency 



3 



During the past decade, various names have been employed to des- 
cribe the syndrome of acute renal insufficiency. The phrase, "lower 
nephron nephrosis, " was popularized by Lucke in 1946, but the condition 
is also referred to as the crush syndrome, traumatic anuria, acute uri- 
nary suppression, hemoglobinuric nephrosis, "kidney shutdown, " and 
necrotizing nephrosis. Yet the term acute renal insufficiency, or acute 
renal decompensation, is more truly descriptive of the altered physiology. 

Acute renal insufficiency denotes sudden failure of the kidneys to 
produce urine in adequate volume and concentration to prevent the reten- 
tion of toxic metabolites. It is analogous to a shock-like syndrome mani- 
fested by sudden decompensation or failure of the renal functions. 

The gravity of the clinical and biochemical problem will depend upon 
the severity of the injury or illness and the response of the individual 
thereto. In the majority of cases of acute renal failure, body trauma 
initiates complete but transient anuria. This is followed in a few hours 
by a period of one, two, or even three weeks of severe oliguria with only 
30 to 300 ml. of urine each day. Progressive uremia rapidly develops 
due to retention of metabolic waste products. If the patient survives this 
hazardous period, the oliguric phase is replaced spontaneously by diuresis 
characterized by increase in the daily urine volume from 300 or 400 ml. 
to, perhaps, 3000 or 4000 ml. during the next week or two with gradual 
clearance of toxemia. 

The clinical course will vary greatly from patient to patient and is 
constantly fraught with great danger, not only during the phase of oliguria 
but also during the diuretic phase. Cardiovascular, gastrointestinal, and 
neuro-muscular signs and symptoms may appear, heralding extremely 
dangerous complications. The outcome will be determined largely by the 
physician's understanding and knowledge of the pathologic changes, not 
only in the nephrons, but also in the concomitant and extreme derange- 
ments of the basic physiology of vital bodily functions. 

Intelligent history-taking must be predicated on a thorough knowledge 
of the causes of acute renal insufficiency which fall into three major groups. 
In the first instance, the immediate renal insult follows from trauma of 
massive wounds and multiple fractures, severe head injury, profound 
hemorrhage from any source, severe anoxia, carbon monoxide poisoning, 
and extreme fluid loss, as in intestinal obstruction or severe diarrhea. 
In the second group, excretion of pigment is the most dramatic feature. 
This promptly appears following the crush syndrome, incompatible blood 
transfusion, blackwater fever, hemolysis secondary to transurethral 
prostatectomy employing distilled water, severe burns, heat stroke, 
icterus neonatorum, hemorrhagic fever, and the hemoglobinurias in the 
crisis of sickle cell anemia. The third group is characterized by nephro- 
toxic substances or sensitizing agents which directly attack the nephrons. 



4 



Medical News tetter, Vol. 25 No. 3 



This occurs in heavy metal poisoning from uranium, bismuth, mercury 
and phosphorus salts, or with toxic organic compounds such as, carbon 
tetrachloride, mushroom poisoning, blackwidow spider toxins, and certain 
snake venoms. It is all too frequent an occurrence in eclampsia and has 
been reported in sulfonamide sensitivity, and serum sickness, resulting 
from endotoxins of hemolytic staphylococci, meningococci, and murine 
typhus, and also following excess administration of nephrotoxic antibiotics 
such as thiomycin, the bacitracins and the polymyxins. 

These etiologic factors are of prime importance in establishing the 
diagnosis. This is not difficult when an accurate history of the patient 
establishes the fact that the urinary output of the patient has suddenly 
been reduced from a normal volume of 1000 or 1500 ml. to 50 or 250 ml. 
per day. If total anuria develops and persists for more than 24 hours, 
the probable cause is total obstruction of the urinary tract. This should 
be searched for diligently, and if found, should be promptly eliminated. 

Prompt recognition of acute renal failure is mandatory if a fatal 
outcome is to be avoided by means of proper, conservative management 
during the very first few days or weeks of this alarming disorder. If the 
physician is alert to the probability of acute renal failure as a complica- 
tion of traumatic events and overwhelming illness, the diagnosis is not 
particularly difficult. Many cases of mild renal decompensation are un- 
doubtedly overlooked and proceed to full recovery either without benefit 
of, or in spite of, clinical intervention. Nevertheless, if the necrotic 
lesions of the renal tubules are sufficient in number and extent so that 
widespread degeneration of nephrons develops, acute renal decompensa- 
tion becomes very serious and extremely difficult to manage, and too- often, 
terminates fatally. 

The diagnostician should be cognizant of the mild transient oligurias 
and azotemias which may accompany various combinations of dehydration, 
depletion of electrolytes, metabolic acidosis, and metabolic alkalosis. 
These derangements will usually disappear promptly with adequate hydra- 
tion of the patient. If trauma is sustained without development of the shock 
syndrome, reflex anuria or transient oliguria may be present for several 
hours, is usually self-limiting, and neither precipitates nor indicates 
acute renal insufficiency. Bloody oliguria may be prominent also in renal 
vascular accidents, acute glomerulonephritis, extensive pyelonephritis, 
and in progressive exacerbations of chronic kidney failure. Bilateral 
ureteral calculi may cause sudden and total anuria, which also could 
result from obstruction of a single ureter if only one kidney is present. 
Overwhelming sulfonamide crystalluria may cause bilateral ureteral ob- 
struction. Metastatic carcinoma within the pelvis may block both ureteral 
orifices and induce total anuria. 

Other causes of extreme oliguria include rapidly advancing hyper- 
tensive cardiovascular disease associated with nephrosclerosis and bi- 
lateral occlusion of the renal arteries as by emboli, thrombi, or dissecting 



Medical News Letter, Vol. 25, No. 3 



5 



aneurysm. Bilateral cortical necrosis of the kidneys can and does occur in 
overwhelming septicemia and as a complication of the toxemias of pregnancy. 
In both conditions, the urine is bloody and very scanty. Such possibilities 
should be borne in mind and ruled out. The chief asset in the differential 
diagnosis of sudden oliguria is an accurate history of the present illness, 
usually prolonged or profound shock following trauma. 

Treatment is difficult and hazardous. It must be predicated on an 
understanding of the pathologic changes which alter the physiology of the 
renal tubule or lower nephron. 

The basic principle of treatment during oliguria is the avoidance of 
overhydration (with blood or salt solution) which induces pulmonary edema. 
More patients are killed than cured by too energetic or overzealous therapy. 

Fluid intake must be calculated accurately every 1Z or 24 hours, based 
on the sum of fluid output (urine, stool, and vomitus) plus a daily allowance 
of 750 ml. to cover the "insensible loss" of water in the form of perspira- 
tion, and as water-vapor through the lungs. Ten or twenty percent Dextrose 
in distilled water for injection is the fluid of choice. This should provide 
100 gm. of carbohydrate daily to prevent starvation ketosis. 

Diuresis usually begins spontaneously from the 7th to the 12th day. 
Fluid volumes must now be calculated to allow for the greatly increased 
urine output, amounting to 3000 or 5000 ml. daily. Overestimation may 
precipitate pulmonary edema; underestimation will result in dehydration. 
As soon as vomiting ceases, the patient may be given nourishment by 
mouth in the form of carbohydrate and fat. A butterfat soup will provide 
high caloric content and is usually well tolerated in the late diuretic phase. 
Small amounts of protein (20 to 30 gm. ) may then be added gradually to 
the diet. 

In the event the diuresis fails to appear by the 10th to the 12th day, 
the danger of death from uremia or by potassium intoxication is very real. 
Emergency measures become imperative. They include peritoneal irriga- 
tion, gastrointestinal lavage, administration of ion-exchange resins, ex- 
change transfusions or, preferably, extracorporeal dialysis by means of 
an artificial kidney. Approximately two -thirds of selected patients sub- 
jected to hemodialysis can be "saved" by this procedure (artificial kidney). 

Blood transfusions are treacherous in the oliguric and early diuretic 
phases of the syndromes and, if employed, must be given sparingly, because 
of the danger of precipitating pulmonary edema. Diuretic agents can not 
be too strongly condemned at any time during treatment of the syndrome. 

Conservative m ana gem ent- - per si stent and prolonged--is the preferable 
form of therapy (70% successful) in lower nephron nephrosis. Hemodialysis 
by means of an artificial kidney may be mandatory and often is life-saving in 
acute potassium intoxication and/or fulminating uremia. Yet, it is not an 
elective procedure comparable to definitive surgery. It should be reserved 
for true emergencies, which can be avoided in the main by early and accurate 



6 



Medical News Letter, Vol. 25,. No. 3 



diagnosis of acute renal insufficiency and adequate, but cautious, therapy 
of this syndrome, ( 1954 Wellcome Prize Essay, Military Medicine, Jan., 
1955; Capt. C.C. Shaw, MC USN, Philadelphia Naval Shipyard, U.S. Naval 
Base, Philadelphia) 

* * * * * * 
Ballistocardiography 



Ballistocardiography is admittedly a controversial subject. The 
technique clearly provides information about the circulation not obtainable 
by other readily available clinical methods. This has led to precipitous 
clinical use by some physicians with the inescapable result that diagnostic 
and prognostic claims have been made without clear justification. Opposed 
to this attitude are those who approach its clinical use with great caution 
and employ it as a research tool to try to learn more about the method and 
its possible application to cardiac disease. The group discussed in this 
article is in this latter category. 

Three types of the ballistocardiograph are in common use: (1) the 
Starr High Frequency Undamped Bed; (2) the Low Frequency Critically 
Damped Bed of Nickerson, and (3) the Direct Body Pick-up, proposed and 
popularized by Dock. {Records may be recorded as displacement of the 
body or as velocity or acceleration. ) The use of these three types of 
ballistocardiographs in the clinic has led to the accumulation of extensive 
empirical data on various disease states. The results of analysis and 
study of these data from many clinics are somewhat discouraging. Thus 
far, the ballistocardiogram has made little contribution to knowledge of 
valvular heart disease or of congenital heart disease, with the exception 
of coarctation of the aorta, in which a reasonably definite pattern is fre- 
quently found. 

Many research groups have been intensively investigating the ballis- 
tocardiograph as a means of bridging a vital gap in the management of 
patients with coronary artery disease. Every experienced clinician knows 
that he is virtually powerless to predict the outcome of this disease. He 
never knows when it may appear in those he examines and finds to be 
apparently normal. Ballistocardiography has aroused keen interest be- 
cause it provides a new and different kind of information about the functional 
state of the circulatory system, related to the pumping action of the heart. 
This interest was considerably sharpened by the finding of Starr that ballis- 
tocardiograms of patients with coronary artery disease are not infrequently 
abnormal when all other tests of the circulation are normal. 

From similar studies by other workers, it is apparent that no specific 
wave form abnormality indicative of coronary artery disease, exists, but 
that the group of patients with coronary artery disease have a somewhat 



Medical News Letter, Vol. 25, No. 3 



7 



higher over-all incidence of abnormal wave forms. Clinically normal 
subjects may have abnormal records and patients with coronary disease 
may have normal records, and one can only speculate upon the meaning 
of these data. Two points seem significant: (1) Abnormal ballistocardio- 
grams are sufficiently uncommon in both young controls and young patients 
to make one suspicious of a young person with an abnormal record. (2) A 
normal record in older persons should, perhaps, be regarded with opti- 
mism. 

The use of stress tests by the authors has been disappointing, and 
the only one that has been encountered that impressively differentiates 
between normals and patients with coronary artery disease, is one based 
on the effect of cigarette smoking. 

Clinical comparisons of the ballistocardiographic abnormalities of 
patients and presumably normal controls are admittedly of great interest. 
However, they are not as yet considered a valid basis for definitive differ- 
ential diagnosis- -a goal which the champions of the technique hope may be 
attained. 

This dependence upon empirical studies results from a deficiency 
of experimental work which intimately relates the form of the ballisto- 
cardiogram to the various physiologic events occurring in the circulatory 
system. The clinical data collected empirically by long-term patient and 
normal control studies alone is unlikely to provide the full knowledge that 
is needed. This possibility, coupled with the scant understanding of the 
physiologic meaning of ballistic waves, has made some investigators in 
the field look elsewhere for progress. It has long been recognized that tne 
physical properties of both the body and the instruments employed to 
measure the cardiovascular forces generated within the body, were such 
as to make errors in methodology inescapable. 

Some progress will come from completion and extension of follow-up 
studies already begun by the authors and others upon patients and presum- 
ably normal controls. At present it is hoped that these follow-ups will 
reveal that the coronary artery circulations of normal controls, with nor- 
mal ballistocardiograms, remain efficient longer than those of controls 
with abnormal records. Statistically significant figures, upon which to 
base these hopes, will not be available until such long-term studies, utili- 
zing the conventional and newer aperiodic ballistocardiographic techniques, 
are completed. 

The ideal line of progress should connect definitively the physiologic 
events in the cardiovascular generator with the component waves of as 
faithful a force ballistocardiogram as can be recorded. When this ideal 
is attained, then ballistocardiography will provide, not only information 
upon the clinical cardiovascular efficiency not obtainable by other means, 
but also information which is desperately needed by the clinician to guide 
him both in his therapy and his predictions of the outcome of his patient's 



8 



Medical News Letter, Vol. 25, No. 3 



ills. {Ann. Int. Med., Dec, 1954; M. L,. Singewald, M. D. , Johns 
Hopkins University School of Medicine, Baltimore, Md. ) 

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New Horizons in Cancer 



Generally speaking, the early diagnosis of cancer offers the most 
hope for successful treatment. Educational programs to alert the public 
and to aid the physician in cancer diagnosis and treatment are yielding 
valuable dividends. Education alone, however, is not enough. Urgently 
needed to ease the cancer case -finding burden are practicable screening 
methods. An ideal solution to this problem would be a simple, inexpensive 
chemical or blood test as useful as the Wassermann test for syphilis. 

Since 1948, a program to evaluate the old tests and to develop new 
ones has been conducted, with financial and technical assistance from the 
National Cancer Institute, by investigators at the medical schools of Tufts 
College and the universities of Washington, Alabama, Tennessee, and 
Kansas. Much good work has been done by these and other workers in 
this field and reported in the literature. None of the tests evaluated so 
far has been found sensitive and specific enough for clinical use. However, 
the approach seems hopeful. The fact that certain tests are effective to 
some extent is an indication that tangible changes do occur in the body of 
the cancer patient, and that these changes may be measurable in a diagnos- 
tic procedure. For instance, it is known that there are changes in the body 
chemistry of cancer patients. In some patients, with cancer of the pros- 
tate, the acid phosphatase level is increased. Measurement of prostatic 
acid phosphatase has been developed to the point where several labora- 
tories are evaluating it as a means of diagnosing prostatic cancer. Other 
promising procedures now being investigated include a serum flocculation 
reaction, the use of radioactive tracers, and means of detecting abnormal 
steroid in the blood or urine. 

Although a practical general diagnostic test for cancer appears to 
be still in the future, considerable progress has been made in the develop- 
ment of tests to aid in detecting cancer of specific sites. The most useful 
of these is the cytologic examination developed largely by G. N. Papanicolaou. 
It is established as a valuable complement to other clinical procedures in 
early diagnosis of cancer, particularly of uterine cancer. Many qualified 
persons have been trained in the cytologic test and numerous clinics and 
physicians in general practice are employing it routinely in cervical cancer 
diagnoses. Variations of the original cytologic technique have been devel- 
oped to aid in the detection of cancer of the lung and of gastric cancer. 
These variations show considerable promise when used in combination with 
other procedures. Cytology is being evaluated as a screening test for cancer 



Medical News Letter, Vol. 25, No. 3 



9 



of the genito-urinary tract, the rectum, and the colon. Also under study 
are applications of the cytologic examination to breast secretions and 
spinal fluid. 

The value of vaginal cytology as a detector of early cervical cancer 
has been indicated in many clinical investigations. One of the most recent 
studies concerned more than 5000 women who received cytologic examina- 
tions by private physicians. The study reported that the examinations had 
revealed 48 definitely curable asymptomatic cervical cancers. The study 
also pointed out the economic feasibility of this screening procedure, esti- 
mating that its cost per private case is within the keeping of many other 
laboratory procedures. 

Cytology provides, not only a means of detecting cervical cancer in 
its incipiency, but also, material for study of the development of the dis- 
ease. Research of this type is under way which may answer questions 
that bear directly on the problem of controlling uterine cancer. Questions 
are asked such as : Do the intraepithelial or "early" cancers progress 
invariably to invasiveness? How frequent is "early" cervical cancer? 
How many of these cancers regress spontaneously? 

A number of studies seeking the answers to these questions have 
yielded significant preliminary findings. The University of Tennessee 
College of Medicine, with the support of the National Cancer Institute 
and other groups, is applying vaginal cytology in a mass - screening sur- 
vey for uterine cancer and intraepithelial cancer among 165,000 women 
in Memphis and Shelby County, Tennessee. 

The results obtained in the screening of the first 70,000 women are 
very encouraging. The cytology findings were suspicious or positive in 
1327, or 1.9% of the women. Tissue biopsy studies have been completed 
in 1076 of the 1327 cases. The biopsy diagnoses were positive in 51% of 
the cases; borderline, suspicious, or inconclusive in 15%; and negative 
in 34%. Vaginal cytology resulted in false positives in only 369 cases, 
or 1/2% of the 70,000 women screened. From the point of view of cancer 
control, it is especially significant that 88% of the 282 confirmed cases 
of intraepithelial cancer of the cervix were unsuspected prior to cytology, 
and 29% of the 245 confirmed cases of invasive uterine cancer were un- 
suspected. 

Also of particular interest is the age distribution of these cancers 
among the cases screened in the Memphis cytology study. On the average, 
the women with intraepithelial cancer are about 20 years younger than the 
women with invasive uterine cancer. The median age of the women with 
early cervical cancer is 33, while the median age of those with invasive 
cancer is 52. This suggests that preinvasive lesions are present for a 
long enough time to allow for their eradication. 

The Memphis study was begun in July 1952. Cytologic examinations 
of the women will be repeated at yearly intervals, and the study will be 



10 



Medical News Letter, Vol. 25, No. 3 



continued until the incidence of intraepithelial cancer and its relationship 
to the incidence of invasive uterine cancer are determined. (Science, 
31 Dec. , 1954; J. R. Heller, Jr., National Cancer Institute, U.S. P. H. S., 
Bethesda, Md. ) 

****** 
Inf ectious Hepatitis in Pregnant Women 

The purpose of this study was to investigate the immediate mortality 
of infectious hepatitis in pregnant women, and also to evaluate liver func- 
tion a year or more after the acute episode in women who survived. 

All cases diagnosed as nonobstructive jaundice at the Boston Lying- 
in Hospital in the past 18 years were reviewed in order to select patients 
for this study. No case occurring more recently than 1Z months was in- 
cluded. Only patients who suffered an acute febrile illness clinically com- 
patible with the disease, now called infectious hepatitis, were accepted 
in the study. In every case, obstructive jaundice had been ruled out and 
there was no evidence of toxemia of pregnancy. Seventeen patients were 
found who met these criteria; two of these had died of the acute disease. 

Evidence indicates that pregnancy imposes a burden on the liver of 
the pregnant woman. If this is the case, an increased severity and mor- 
tality from liver disease, occurring during this period, could be expected. 

Zondek and Bromberg, who followed a group of pregnant women in 
an epidemic of infectious hepatitis in Jerusalem, remarked on the increas- 
ed mortality in pregnant women, (17% of 29 patients studied) but empha- 
sized the role of malnutrition as a factor. In the reported series, 2 women 
died of acute yellow atrophy out of the 17 seen with infectious hepatitis 
during pregnancy. Malnutrition did not seem to be a factor in these deaths. 

Because infectious hepatitis leads to chronic liver disease in some 
cases, and because pregnancy appears to place a load on the liver, the 
authors have attempted to determine whether infectious hepatitis, occur- 
ring in pregnancy, causes an increase in chronic liver disease. 

The frequency of chronic liver disease after infectious hepatitis in 
nonpregnant patients is not clear. Jones states that chronic hepatic im- 
pairment evidenced by continued elevation of the serum bilirubin is not 
rare. Of 1 1 patients, 5 had a serum bilirubin higher than 1.0 mg. per 
100 cc. An additional 3 showed elevation of serum globulin which in 2 
cases was, perhaps, due to pregnancy; another demonstrated hepato- 
splenomegaly and a low serum albumin. Only 2 had entirely normal clin- 
ical and laboratory findings. The frequency of chronic hepatic disease in 
this series was, therefore, higher than one would expect after infectious 
hepatitis in nonpregnant patients according to the studies reviewed in the 
article. 



Medical News Letter, Vol. 25, No. 3 



11 



Of particular interest is the fact that 15 of the 17 cases occurred in 
the last trimester of pregnancy. This weighting is corroborated by Zondek 
and Bromberg, who found 19 of the 29 patients in the second half of gesta- 
tion, suggesting either that infectious hepatitis is more apt to be overt and 
clinically recognizable in the second half of pregnancy, or that pregnant 
women are more susceptible to infectious hepatitis in the latter months 
of pregnancy. 

The results of this study are applicable only to infectious hepatitis 
occurring in the last trimester. The acute severity of the disease at that 
period of pregnancy has been emphasized by Zondek and Bromberg and 
Dill. It is also supported in this series in which the only deaths (two) 
occurred in the last trimester. 

Emphasis was given to the fact than none of the patients under dis- 
cussion had symptoms of liver disease at the time of follow-up examina- 
tion. Thus, although the authors believe that persistent liver damage is 
frequent, it may not be progressive. They believe it possible that the 
abnormalities found are only indicative of damage incurred at the time of 
the infectious hepatitis. There is no evidence of a continuing process that 
will eventually lead to clinical disability, but avoidance of further liver 
damage in these patients is important. 

This brief series of cases suggests that infectious hepatitis, when 
it occurs in the last trimester of pregnancy, carries a higher mortality 
and a greater tendency to chronic liver damage than when it occurs in 
the nonpregnant patient. (New England J. Med., 30 Dec, 1954; H. L. Frucht, 
M. D. , Boston Lying-in Hospital, and J. Metcalfe, M. D., Harvard Medical 
School, Boston, Mass. ) 

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Infectious and Serum Hepatitis 

During the period, 1951-1953, there were 6667 cases of infectious 
hepatitis and 137 cases of serum hepatitis among Navy and Marine Corps 
personnel. These diseases have been of primary interest in preventive 
medicine because their epidemiology is not clear cut. Recently, ques- 
tions were being raised concerning the occurrence of these diseases (1) 
among personnel who have been in the Navy a comparatively short time 
and (2) by geographic area. This brief report attempts to shed some 
light on these questions. 

From the numerical point of view, most of the cases of both infectious 
and serum hepatitis (more than 5 out of every 6) occurred among person- 
nel with one year of service or more. An analysis of rates, by length of 
service, reveals that personnel with less than one year of service are less 
likely to contract these diseases than those with one year of service or more. 



12 



Medical News Letter, Vol. 25 No. 3 



In the occurrence of infectious and serum hepatitis by geographic 
area, it was seen that, numerically speaking, during 1951-1953, almost 
half of the cases of infectious hepatitis occurred among personnel stationed 
aboard ships and about one-fifth among personnel in noncontinental shore 
activities. An inspection of the rates reveals the significance of these 
figures; it maybe seen that, in relation to their strength, personnel aboard 
ship, and especially those stationed at shore -based activities in noncontinen- 
tal areas, contracted these diseases much more often than did personnel in 
the continental United States. The distribution by geographic location is 
based on the individual's last duty station. Many individuals, whose last 
duty station was in continental United States, probably contracted infectious 
hepatitis in noncontinental areas. During the period under discussion, there 
have been very few instances of any concentration of hepatitis cases at one 
activity. 

During 1951-1953, only 15% of the serum -hepatitis cases occurred 
among personnel in noncontinental shore stations. Continental United 
States shore stations and ships each accounted for more than 40% of the 
new cases. Relating these cases to strengths in the respective areas to 
obtain rates, gives a picture of the relative incidence among personnel in 
these areas. Although the differences in. the incidence rates for serum 
hepatitis in the three areas are not as great as for infectious hepatitis, 
nevertheless, the one outstanding fact remains that the hazard of contract- 
ing serum hepatitis is greatest among personnel attached to noncontinental 
shore stations. (Statistics of Navy Medicine, Jan., 1955) 

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Management of the Tuberculous Hip Joint 

A steady, although gradual improvement in treatment of the tuber- 
culous hip joint has been observed, and more satisfactory results have 
been obtained. The crowning achievement in treating tuberculosis has 
been the introduction of antibiotics. 

One of the chief difficulties at present in patients with hip -joint 
disease is the accurate diagnosis of the early case. Frequently, a pa- 
tient is seen with the clinical signs of arthritis of the hip or, as it is 
called, transient arthritis (an "observation hip"), with a limp, limita- 
tion of movement by muscle spasm, and perhaps, pain. The history is 
usually of a few days' duration with little evidence of a systemic illness- - 
although there may be a mild pyrexia--and a "reported normal" roent- 
genographic appearance of the joint. 

Accurate diagnosis in such a patient is so important that every pos- 
sible means of diagnosis must be employed, as the prognosis has been 
so immeasurably improved by the introduction of chemotherapy. It is 



Medical News Letter, Vol. 25, No. 3 



13 



now known that there is a reasonable chance of obtaining a mobile joint 
if the disease is recognized in its early synovial stage; early proof of 
the lesion is, therefore, imperative. 

However, it is obvious that the diagnosis of a transitory arthritis 
from a tuberculous lesion is most difficult. Historically and symptom - 
atically, these are often identical and remain so for weeks during the 
early treatment which is usually by means of traction for the relief of 
pain and resulting spasm. 

Statements are glibly made of doing a biopsy, of culture, and of 
guinea-pig inoculation, as though these gave an absolute diagnosis; but, 
unfortunately, this is not always so. The author believes that, in a few 
cases, because of the absence of confirmatory evidence of this nature, 
reliance must be placed on a summation of all facts which can be inter- 
preted by using clinical judgment based upon experience- -surgical acumen. 

In any consideration of the treatment of the tuberculous hip joint, it 
is obvious that chemotherapy has allowed the return to the more radical 
methods of local attack, some of which in years gone by were disappoint- 
ing because they were so often followed by sinus formation and dissemi- 
nation of the disease. However, it should always be borne in mind that 
tuberculosis is a general disease and that the joint lesion is but a metas- 
tatic manifestation of it. Thus, the involvement of the deeply situated 
glands, inaccessible, insidious, and in issue far more dangerous than 
the lesion itself, should ever be borne in mind. This makes the sana- 
torium regimen still imperative. 

Children responded well to this regimen, with healing of the adeni- 
tis as well as of the concomitant -bone lesion, but this took a long time. 
Many patients required sanatorium treatment for 5 years or more in the 
days before the introduction of chemotherapy. This period of prolonged 
immobilization led to many complications, such as premature fusion of 
the epiphyses, with shortening of the extremities and resultant stunting, 
both physical and mental, as well as other forms of morbidity. 

The author noted that adults did not respond so well and often had 
reactivation of the glandular focus with a substantial late mortality from 
associated lesions. 

Streptomycin and associated drugs have permitted a direct surgical 
attack on the joint; in patients seen early, therefore, there is hope for a 
mobile joint, and in patients seen late, a shorter period of immobiliza- 
tion, an earlier and quicker fusion, and fewer, if any, complications. 

Undoubtedly, the best results are now obtained by the use of strep- 
tomycin in combination with other drugs and surgery. These do not 
supersede a sanatorium regimen, but merely reduce the time in which 
it is necessary. 

In Scotland, the author believes that perhaps there is more opti- 
mism than in America about the future of skeletal tuberculosis now that 



14 



Medical News Letter, Vol, 25, No. 3 



antibiotics are available. Streptomycin, augmented by para-aminosalicylic 
acid, or substituted for by isonicotinic acid hydrazide (isoniazid), gives the 
orthopedic surgeon a far greater control of the course of the disease at any 
stage. 

Chemotherapy for the Mycobacterium tuberculosis has been long 
enough in general use for its acceptance as the most useful adjunct to 
surgery, the principles of which, in turn, must be modified and advanced 
so that its properties are fully utilized in the treatment of incapacitating 
condition. Antibiotics may be expected to shorten the course of the disease. 
Rigid immobilization for a long time is probably no longer essential, and 
it is hoped that the unfortunate effects of immobilization, such as renal 
calculi, osteoporosis, and premature epiphyseal closure, leading to a 
woefully short extremity, will also become things of the past. The author 
fully expects that the bacteriologist and the biochemist will produce other 
chemotherapeutic agents of greater bacteriostatic and penetrating proper- 
ties, and that surgical treatment will correspondingly advance, resulting 
in more mobile hips. There will, however, often be some derangement 
in the usual architecture of the surfaces of this weight-bearing joint, be- 
cause most tuberculous lesions heal by fibrous tissue or recalcification, 
without regeneration of the original tissues. The complication of osteo- 
arthritis is thus likely to arise with its own peculiar difficulties in treat- 
ment, and arthroplasties will have to be carried out at a later stage of 
life. Most orthopedic surgeons will be ready and pleased to treat this 
complication when it arises, after the patient has had the use of a func- 
tioning hip joint for several years. 

To achieve bony ankylosis of a tuberculous hip joint (particularly 
in the advanced intra-os seous type of lesion) must be the aim and method 
of choice because of its long proved efficacy; However, the author sug- 
gests that now, more than ever, early diagnosis of the lesion by biopsy 
must be sought (with its concomitant decompression of the tuberculous 
lesion of the hip joint) so that the patient is left with a functioning and 
mobile hip. ( J. Bone & Joint Surg. , Dec. , 1954; Prof. W. Mercer, 
Edinburgh, Scotland) 

$ $ $ jje * # 

Surgical Treatment of Polycystic Kidney 

Because one learns by iteration and reiteration, it is important to 
repeat as often as possible that destructive polycystic disease of the kid- 
ney must be diagnosed early in its course, and that many patients treated 
for Bright's disease, associated with hypertension and uremia, are actual- 
ly suffering from polycystic disease. The usual bilateral nature of the 
disease challenges the surgeon's ingenuity, and no other operation on the 



Medical News Letter, Vol, 25, No. 3 



15 



kidney requires greater deliberation and keener judgment than does surg- 
ical treatment of this condition. 

With modern diagnostic methods - -excretory and retrograde pyelo- 
graphy and arteriography studies and perirenal insufflation- -the con- 
dition can be recognized in most cases. The diagnosis and treatment of 
concomitant ureteral stricture preserve kidney tissue and prolong life. 

Some relevant characteristics of polycystic disease, its complica- 
tions and the indications for conservative operation for relief of intra- 
renal tension and intractable pain, as well as those for radical intervention 
(nephrectomy), are presented in this article, and a case of polycystic kid- 
ney disease and cholesteatoma, treated by nephrectomy, is reported. 
Although polycystic kidney disease is usually bilateral, some maintain that 
it may be unilateral. 

Associated congenital anomalies are fairly common: harelip, super- 
numerary fingers or toes, club feet, intracranial aneurysms and others; 
in 40% of all cases, cysts of the liver, uterus, spleen, and other organs 
are also present. Congenital malformation of the polycystic kidney itself 
is relatively rare. 

Other conditions may coexist with the polycystic disease- -ptosis, 
torsion, calculi, and hydronephrosis are among them. When torsion is 
present, it is well to carry out nephropexy. The case of a patient is 
reported in which intractable pain was relieved by nephropexy and sym- 
pathectomy, and by decapping, puncture, and cauterization of numerous 
cysts in the kidney and liver. Kidney stones are removed in the usual 
manner. It is better to remove stones situated low in the ureter by ureter- 
olithotomy than to risk cystoscopic manipulation. Plastic operations for 
hydronephrosis are performed as in cases without polycystic disease. 

In addition to impairment of renal function, two conditions that arise 
from the disease are pain due to enlargement of the cysts, and back pres- 
sure due to ureteral stricture. Ureteral drainage should be included in 
the over-all treatment of this progressively destructive disease. Medical 
treatment is confined to dealing with the concomitant conditions - -pain, 
complications of stricture- -and perhaps hormonal therapy. 

Because of the customary bilaterality of this disease, conservative 
surgical treatment is preferable unless circumstances make more radical 
treatment necessary. Progressive enlargement of the cysts increases 
intrarenal pressure and causes destruction of renal parenchyma. In order 
to arrest this pathologic process, Rovsing devised his multiple puncture 
operation. It is generally agreed that the indications for this operation 
are: (1) diminution of renal function, recognized in gradual rise in blood 
chemical values and decrease in renal excretion of urine; (2) persistent 
pain; (3) intracystic hemorrhage; (4) progressive elevation of blood pres- 
sure; (5) limited renal involvement, and (6) poor results of medical treat- 
ment. 



16 



Medical News Letter, Vol. 25 No. 3 



The permanent therapeutic value of decapping and puncturing cysts 
has been questioned because some cysts may refill and unpunctured cysts 
progressively enlarge. Secondary infection and urinary fistula can be 
prevented by proper technique. It is the consensus that, if patients are 
carefully chosen and operation is performed early enough in the course 
of the disease, the patient's life is unquestionably prolonged. 

In the presence' of accompanying destructive diseases localized to 
either pole of the kidney, one should not hesitate to carry out partial 
resection, and for bifid kidney, heminephrectomy. 

The surgeon is loath to carry out nephrectomy for this disease but 
he should not hesitate to operate for definite destructive lesions of the 
kidney. Operation is c ontraindicated if renal function is too poor, a status 
usually reflected in a nonprotein nitrogen level of over 60 mg. per hundred 
milliliters of blood. Indications for nephrectomy are cancer, caseocaver- 
nous tuberculosis, pyonephrosis, irreversible extensive hydronephrosis, 
intractable diffuse pyelonephritis, voluminous and numerous calculi and 
exsanguinating hemorrhage. After unilateral conservative or radical 
operation, the remaining kidney may decrease in size. 

Nauman and Sabatine reported a case of cholesteatoma of the kidney. 
Although this tumor commonly occurs in the brain and occasionally in other 
parts of the body (intestinal tract, genitalia, eyes, and elsewhere), their 
review of the literature revealed only 8 authentic cases of cholesteatoma 
of the urinary tract, none accompanied by polycystic kidney disease. 

The first case of cholesteatoma complicating polycystic disease of 
the kidney is reported. This condition was treated by nephrectomy and, 
thereafter, by repeated dilation of the remaining ureter. The patient was 
well two years and five months after the operation. ( J. Internat. Coll. 
Surgeons, Dec. , 1954; C. P. Mathe, M. D. , San Francisco, Calif.) 

The Painful and Stiff Shoulder 

For many years, confusion and disagreement have existed with regard 
to the pathologic character and the treatment of a painful, stiff shoulder. 
The syndrome of severe progressive pain in the shoulder in a person of 
middle or advanced age, which progresses in spite of recommended forms 
of treatment, is a frequent and annoying problem. The multiplicity of dif- 
ferent treatments recommended in the literature indicates that no treat- 
ment has been satisfactory. There is almost total ignorance of the path- 
ogenesis, as well as minimal information as to the pathologic picture, and 
consequently, the diagnosis is difficult. Finally, writers on the subject 
are at variance as to what constitutes a satisfactory result. 



Medical News Letter, Vol. 25, No. 3 



17 



The purpose of this article is to attempt to review and coordinate 
the experience of all writers and evolve a logical plan of treatment. A 
proposition is made to standardize the results, so that proper evaluation 
of the treatment can be obtained. 

A thorough examination of the. shoulder, with attention directed to 
the following points, is a prerequisite to determining the type of treat- 
ment to be given. The first point of tenderness is above the greater 
tuberosity and just adjacent to it. When the trouble is limited to this 
region, the patient may shrug the shoulder on attempting abduction and 
point to this spot as the site of discomfort. Alternately, at the same 
examination, the shoulder movement may be performed freely, without 
any discomfort. This is indisputable evidence that the disturbance in the 
mechanism of abduction is a factor in producing or exciting the reaction 
around the cuff of the humeral head. Whether the disturbance of the mech- 
anism is primary or secondary to a lesion or an inflammatory process in 
the cuff at this region, remains to be studied. When the condition is slight- 
ly more advanced, tenderness is demonstrable along the bicipital groove. 
The various tendon signs described by other authors, including Yergason, 
may be demonstrable. 

Active abduction and forward flexion are' next tested. Both of these 
motions are done, first with the arm in internal, and next in external ro- 
tation. The rotation of the humeral head may bring the tender lesion 
around to the point of greatest compression and will bring out the discom- 
fort and shrugging mechanism that might not be demonstrable in other 
phases of the arc of rotation. Passive motion is next tested and compared 
with active motion. As a general rule, in the late stages of frozen shoulder, 
the passive motion does not differ greatly from the active. This is in con- 
trast with the condition observed in the early,, nonadhesive stage, in which 
the passive motion greatly exceeds the active and may even possess a full 
range. 

Next, a local anesthetic is injected into the tender area to remove 
the possibility that pain will restrict the range because of the setting up 
of muscle spasm, and the ranges of active and passive motion are once 
again determined. If a full range of active motion is obtained, the con- 
dition may be considered in a very early stage and without adhesions. If, 
on the other hand, restriction is marked, and is comparable to the range 
observed before anesthetization, the presence of adhesions and classifica- 
tion of the lesion as a late one are definite. If good abduction is obtained 
actively, attempts to maintain the position against resistance may demon- 
strate that the arm is weak and may drop to the side. This strongly suggests 
that the maintenance and fixation of the head in the glenoid is not obtainable 
because of interruption of the musculotendinous cuff. 

Roentgen films are taken. In the typical frozen shoulder, the humeral 
head is very high in the glenoid and the upper edge of the head is super- 
imposed upon the acromion. If downward traction is exerted on the extremity 



18 



Medical News Letter, Vol. Z5, No. 3 



or if the biceps flexion is strong and exerted against resistance, the hum- 
eral head should normally descend and the humero -ac romial space should 
widen. Failure to demonstrate a difference from the previous film indi- 
cates that the capsule is markedly contracted, and adhesions and fixation 
are extreme. The greater tuberosity may demonstrate reduction in size 
(recession), and there may be sclerotic and irregular changes at the point 
of attachment of the cuff. This indicates long-continued friction and irrita- 
tion of the area. The area just proximal to this tuberosity is the trigger 
point that sets up the vicious cycle. These observations about the tuber- 
osity are obtainable in practically all cases of frozen shoulder. They 
are pathognomonic of long -continued compression and irritation where 
the tuberosity comes in contact with the acromion. 

Conservative treatment is the modus operandi in all cases. The 
patient is placed in absolute bed rest with the arm hanging in a dependent 
position, or traction is exerted distally to eliminate the humero-acromial 
compression. A few patients gain a great deal of comfort by placing the 
arm in wide abduction so that the tuberosity has passed beyond the acro- 
mion and lies medially in an area of relatively little compression. This 
is effective only in the early stages. Ice packs are applied for prolonged 
periods for their anesthetic effect and for the reduction of congestion. 
Sedatives are given until the pain subsides completely. Almost complete 
elimination of discomfort may take from one to six weeks. This is follow- 
ed by exercises designed to strengthen the biceps muscle without permit- 
ting abduction. The increased tonicity of the biceps muscle, theoretically, 
is effective in creating a depressor effect on the humeral head. Pendulum 
exercises, to stretch the capsule and create enough redundancy inferiorly 
to permit downward descent of the head during abduction, are started. 
Next, graded active and passive abduction exercises are instituted. The 
abductors are stretched. The arm is maintained in neutral rotation. After 
over 90% abduction is obtained, external and internal rotation stretching 
and exercises are done. By directing the patient to use a bath towel in 
the same manner as in drying the back after a bath.7 one hae an effective 
means of combining active and passive exercises in internal and external 
rotation at home. The patient is also instructed to attach a pulley very 
high on a door, and by means of a clothesline, which is held by the ends, 
alternately to raise and lower the affected extremity. This is an effective 
passive exercise to increa'se the range of motion in the shoulder and to 
stretch the inferior capsule and the abductor muscles. Wall-climbing 
exercises are also done. 

The indications for arthrotomy are definite. They are (1) failure 
to respond to conservative treatment as regards both motion and pain; 
(2) too slow an improvement, economically undesirable; (3) recurrence; 
and (4) suspected gross damage to the cuff, tendon, and bony structures. 
{J. Internat. Coll. Surgeons, Dec, 1954; S. L,. Turek, M. D., Mt. Sinai Hospital, 
Chicago, 111. } 



Medical News Letter, Vol. 25, No. 3 
Public Health Aspects of Periodontics 



19 



The widened scope of modern dentistry presupposes a concern, not 
only with restoration of lost tooth structure, but also with care of the sup- 
porting tissues of the teeth and the oral mucosa in both health and disease. 
The inter-relationships of medical and dental diseases demand of the den- 
tist much basic knowledge of disease processes. Of special importance 
is the role of periodontics in dentistry, because periodontics is that special- 
ty of dental science which is concerned with the study, prevention, and treat- 
ment of diseases of the supporting tissues of the teeth. Specialty status is 
accorded periodontics because it is a well organized body of knowledge and 
requires a high degree of skill in performance. 

The prevalence of dental diseases is further complicated by the in- 
sufficiency of personnel to render adequate care to all of the public. The 
time needed for dental treatment, and the necessity for periodic repetition 
of dental care throughout life, are added difficulties which need to be over- 
come. 

Periodontal disease is a chronic ailment. That some form of perio- 
dontal disease affects the community as a whole is a fact which has been 
revealed by clinical observation and epidemiological studies - -inadequate 
as many of these may have been. Probably more than any form of dental 
disease, periodontal disease may and does have injurious effects in other 
remote areas of the body. Opinions are prevalent that periodontal disease 
possibly initiates, and probably aggravates, some systemic diseases. The 
mouth is the body's major avenue of entrance for bacteria. As a matter 
of fact, the likelihood of protection of bacteria in peridontal pockets is 
very great indeed. 

Periodontal diagnosis embraces those clinical and laboratory pro- 
cedures necessary to disclose the distinctive nature of the disease by its 
symptoms. The symptoms which a disease process presents are actual 
clues which the diagnostician must use in piecing together the whole story. 

The duty of dentists to examine carefully the entire mouth of each 
patient is by no means idealistic; to look at the teeth only is no longer 
sufficient. 

Upon the dentist's recognition of incipient carcinoma or venereal 
diseases or metabolic disturbances depends the immediate referral to a 
source of corrective therapy. The consequences of delayed, inadequate 
diagnosis are the uninterrupted progression of cellular growth, tissue 
destruction, systemic invasion, and ultimate death. The spread of many 
infectious diseases, if the latter are recognized or properly diagnosed by 
any member of the health team, could be reduced significantly. Just how 
important these observations are to the periodontist is readily recognized 
when it is understood that, perhaps more than any other dental specialty 
which contributes to complete oral rehabilitation, periodontic s is intimately 



20 



Medical News Letter, Vol. 25, No. 3 



associated with preventive dentistry, wholly dependent upon oral diagnosis, 
and vitally concerned with dental therapeutics. As important units of the 
health team, periodontists in particular, and dentists in general, must 
look beyond the teeth if they are to assume the full responsibilities and 
obligations of public health to which they are committed by their own 
pledge of honesty and fairness to patients. 

As complicated as are the relationships of systemic factors to the 
etiologv of periodontal disease, and as few as have been the clinical and 
laboratory investigations under controlled conditions to determine the 
nature of these relationships, it can hardly be denied that systemic factors 
do influence the health of the periodontal tissues and the course of perio- 
dontal disease. 

Calculus, oral habits, mouth breathing, inadequate interproximal 
contact, irritating effects of poor restorations, malposition of teeth, and 
occlusal trauma represent some of the local etiologic factors of perio- 
dontal disease. Their correction and the reinstitution of normal physio- 
logic appearance and function of the periodontium are the ultimate objectives 
of therapy. However, the attainment of these objectives is frequently a dif- 
ficult procedure because many factors are involved. Many of these factors 
are not too well understood so that it is necessary for the periodontist to 
use much ingenuity in evaluating therapeutic procedures and arriving at a 
plan of operation for a particular case. The indications and contraindica- 
tions for such procedures as subgingival curettage and gingi vectomy, 
splinting, tooth replacement, drugs, occlusal adjustments, orthodontic 
procedures, diet therapy, and oral hygiene are dependent upon the char- 
acteristics of each patient. 

The treatment of some types of periodontal disease is, therefore, 
a technical function of the specific dentist, whether general practitioner 
or specialist. There can be no mass application of technical procedures 
in periodontal therapeusis. The unit of operation is a single person neces- 
sitating individuality of treatment by a particular clinician. The epidemiol- 
ogist considers the community as the unit of operation. 

The metabolic activity of the cellular elements in the periodontal 
tissues- influences the reaction of the latter to irritative stimuli. It is, 
therefore, most necessary to have an efficient performance of this activity. 
The necessary nutrients assist in maintaining optimum activity so that pro- 
per foods with a sufficiency of vitamins and minerals are indispensable. 

Dietary regimen, role of endocrines, debilitating diseases, oral 
hygiene, the effects of chemical irritants, home care, and the role of 
smoking in ulceromembranous gingivitis are factors which lend themselves 
to the public health educational approach. In a very real sense, their cor- 
rection can be developed as an educational responsibility, requiring com- 
munity-wide health educational effort. 

People are entitled to the benefits of preventive dentistry as an 
essential of over-all preventive medical care. The prevention of periodontal 



Medical News Letter, Vol. 25, No. 3 



21 



disease, together with the maintenance of health of the periodontal tissues, 
are the two most important areas of periodontics with public health impli- 
cations . 

To be effective, a program of prevention must be based upon a tho- 
rough knowledge of causative factors and epidemiological characteristics. 
A recapitulation of the local and systemic etiological factors in periodon- 
tal disease indicates that whosoever is responsible for care and mainte- 
nance must be thoroughly versed in recognizing, not only the conditions 
themselves, but also the factors which predispose to periodontal disease. 
Education, therefore, looms as the major consideration. Certainly, perio- 
dontists must be especially trained, but it is just as important that other 
dentists, dental hygienists, physicians, and nurses should be educated 
about care and prevention of periodontal disease. They must be taught 
that the instructional status of the individual is an important predisposing 
factor of periodontal disease. 

Health workers must foster periodic dental examinations. Moreover, 
they must be taught why it is essential to emphasize home care. Health 
workers must then play a major role in seeing that this information is 
passed on to the public. (J. Dent. Med. , Jan., 1955 ; C. O. Dummett, D. D.S., 
VA Hospital, Tuskegee, Ala. ) 



# # # * * # 



Radioactive I sotopes 

Radioactive isotopes are chemically identical with their stable coun- 
terparts. They behave in the same way in chemical reactions, and are 
handled in the same manner by physiologic and metabolic processes. How- 
ever, their atoms possess the unique property of disintegrating, and emit- 
ting radiation in the act, which makes it possible to follow them through 
all sorts of procedures and reactions. In following them, it is also pos- 
sible to trace the paths of their nonradioactive twins. 

The rate of disintegration of these substances is commonly expressed 
by a statement of their half lives . The half life is the period in which half 
of all the atoms of the particular isotope present will have disintegrated; 
in the next half period half the remainder will go, and so on. Thus, about 
seven half lives are necessary to reduce any given amount of an isotope to 
one percent of its initial value. Half lives of various isotopes range from 
fractions of a second to millions of years; for those useful in medicine, 
for the most part, half lives vary between a few hours and a few weeks. 
Radioactive potassium (K ) has a half life of 12.4 hours; its period for 
reduction to one percent is about 3.5 days. Radioactive phosphorus (P 32 ), 
with a half life of 14.3 days, will not be reduced to one percent until over 
three months have elapsed. 



22 



Medical News Letter, Vol. 25, No. 3 



The amount of any radioactive isotope is expressed in terms of 
curies, or millicuries, or microcuries, the last being the normal one for 
diagnostic procedures. A microcurie of any isotope is that quantity in 
which 37,000 atoms disintegrate per second. If an isotope has a long half 
life, a microcurie of it will have to contain more atoms than if it has a 
short one, to keep up the supply for disintegration. As the amount de- 
creases by this disintegration, what was originally a microcurie becomes 
less, but the reservoir has to keep up the supply for whatever the natural 
rate may be. 

Radioactive isotopes emit beta or gamma radiation, or both. The 
beta rays may be so unpenetrating that a small fraction of a millimeter 
of tissue will stop them all, as in radioactive carbon and sulfur, or they 
may traverse several millimeters, as those from radioactive phosphorus 
do. The most penetrating beta rays, known to be emitted by a radioactive 
isotope with a half life of more than a few minutes, are those from radio- 
active potassium, with a maximum range in tissue of nearly 2 cm. Gamma- 
ray energies range from less than 100 kv. in radioactive iron, to more 
than 2,000,000 volts in radioactive sodium. 

It is evident that both the lifetime and the kind of radiation emitted 
by an isotope will be important considerations in the types of investigation 
that can be made with it. Obviously, a study extending over several days 
cannot be made with an isotope having a half life of a few minutes. 

Two other limitations exist on tests to be performed with radioactive 
isotopes; these may be called the avoidance of chemical effect and avoid- 
ance of radiation effect. Chemical effect would never result if carrier- 
free isotopes we're used. 

Radiation effect would result if the radiation emitted by the test 
dose of the radioactive material were sufficient to bring about physiologic 
changes that might affect the reaction being tested. This will seldom, if 
ever, occur in the human being at present. Most test doses are planned 
to deliver not more than 0.3 r to the patient in the first week, and less 
in any subsequent week; this is assumed to be the permissible dose that 
will have no detectable effects. 

Various types of studies with radioactive isotopes are useful as 
diagnostic aids. This is a different thing from saying that they are 
"diagnostic tests. " Actually, there are, in medical practice, very few 
truly diagnostic tests that reveal that the patient does or does not have 
a certain disease or condition. The Wassermann and Aschheim-Zondek 
are two that come immediately to mind. At present, no test with an iso- 
tope is in this class, although some of them may be before long. 

The biologic or physical studies that can be made with radioactive 
isotopes cover a wide range of phenomena, such as uptake, distribution 
and excretion of an element, turnover rates in particular tissues, and 
the nature of the products of intermediary metabolism, which as yet have 



Medical News Letter, Vol. 25, No. 3 



23 



little or no direct significance as diagnostic aids. However, most of the 
studies now used clinically started as pieces of physiologic research. It 
is probable that others will cross the line from the purely investigative 
to the practical. 

Useful studies as aids in medical procedures are based on one of 
four phenomena: (1) dilution of a known amount of isotope to determine 
the volume of the diluting fluid; (2) rate of transfer from one part of the 
vascular system to another to ascertain some fact about the circulation; 
(3) rate of disappearance of an isotope that has been injected directly 
into a certain tissue, to reveal the state of the local circulation in that 
tissue; and (4) concentration of the isotope in a particular organ or tissue 
to determine something about the local function of that tissue. 

Examples of dilution studies are determinations of the volume of 
blood, plasma, red cells, and extracellular fluid. The basic procedure 
is the same in all cases. A known amount of the isotope to be used is 
injected into the circulation. After an appropriate time for mixing into 
the fluid studied, a blood sample is taken and the dilution determined. 

Studies based on rate of transfer are fundamentally illustrated by 
the determination of circulation time. An isotope can be injected into a 
definite place in the vascular system, rapidly and in a small volume of 
solution; its arrival at another place is observed by a detector located 
there. Time elapsed between injection and detection is circulation time 
between the two points. 

Studies of rate of disappearance of isotope from a tissue offer a 
different index of circulation- -one dealing with the actual nourishment 
of a small fragment of tissue under observation. The isotope, in a very 
small volume, is injected directly into the tissue under investigation, the 
counter placed directly over it, and the disappearance rate observed. This 
procedure is of value in tests of circulation in tubed pedicles used in grafts 
in plastic surgery. 

Concentration of an isotope in a particular tissue, for study of some 
function of that tissue, is best typified by studies of thyroid function with 
radioactive iodine. 

It has always been hoped that radioactive tracers could be found 
that would definitely identify cancerous tissue. Unfortunately, up to the 
present time, this hope has not been borne out. However, it is true that 
any tissue that is metabolizing rapidly will show earlier or higher uptake 
of any metabolite than corresponding normal tissue. This phenomenon 
has been utilized in the attempt to localize tumors not readily demonstra- 
ble otherwise. 

Most popular of these has been the localization of brain tumors. 
The surgeon is anxious for help of this sort. In general, the blood-brain 
barrier inhibits the rapid entrance of nonphysiologic material into the 
central-nervous-system tissues. However, in the presence of inflammation 



24 



Medical News Letter, Vol. 25, Nq. 3 



or of a neoplastic growth, this barrier (whose exact nature is unknown) 
is disrupted and allows the tracer to flood the region. The mechanism 
whereby more of the isotope is concentrated in the tumor than in the nor- 
mal tissue is not known but the concentration does occur. Localization, 
then, depends on counting at symmetrically located sites on both sides 
of the head, and finding where there are differences in level. At present 
the tracer of choice is radioactive iodinated human serum albumin which 
gives rather high differentials with tissue levels remaining stable for two 
or three days. Very small tumors and midline tumors are not readily 
located but some clinical groups report a high percentage of successes in 
large series of cases. 

Recently, procedures have been developed to detect silent metastases 
in the liver, which are among the chief causes of failure in surgical treat- 
ment of cancer. The various liver -function tests and needle biopsy are the 
only laboratory procedures currently available to the clinician for the de- 
tection of such metastases, and they are notoriously unreliable when one 
is dealing with small, solitary or early growths. However, these are fre- 
quently demonstrated by administration of a radioactive tracer and counting 
of points in a pattern over the region. The tracer employed by the group 
at the Los Angeles Veterans Administration Hospital, who first reported 
on this procedure, is iodine-labeled human serum albumin. The tracer 
dose is administered intravenously and the patient studied 24 hours later. 
Counting over a 5 cm. -square lattice pattern is sufficient to show regions 
of increased uptake. Very small or deep-seated masses may be masked by 
normal liver. Nevertheless, in a series of 151 patients studied by the 
group, an over -all accuracy of 95% was obtained. In 32 patients found at 
operation to have metastases, 30 had previously been designated as posi- 
tive by radioactive survey. Of 119 grossly normal, 114 had been within 
the control range for the isotope test. Because preoperative knowledge 
of the existence of liver metastases would be extremely valuable, it appears 
that this test should have wide use. 

Efforts have been made to find a bone -seeking isotope that could be 
used as a detector of bone metastases. Some success has been achieved 
with radioactive gallium; however, this isotope also shows deposti inar- 
thritic areas. In general, thes,e metastases can be found by means of x-ray 
examination as soon as by an isotope tracer. (New England J. Med., 6 Jan., 
1955; E. H. Quimby, Sc.D., Columbia University College of Physicians and 
Surgeons, New York City) 

SjS * ^= * Sjc * 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addres s es. 



j|s * :j! # * # 



Medical News Letter, Vol. 25, No. 3 
Safe Practices for Navy Motor Vehicle Operators 



25 



The following material on Safe Practices includes many instances 
in which the practice you are advised to follow may differ from what you 
are used to doing. These safe practices are based on the experience of 
persons who have made a special study of how to drive safely and effi- 
ciently. These practices are now being taught to nearly half a million 
beginning drivers each year through programs of driver education. 

Read this material with an open mind. The chances are that you 
learned to drive in a haphazard way, possibly from someone who passed 
on to you his own questionable methods. Therefore, you can improve 
your present practices by close study of the following section. Be honest 
with yourself; if you don't use the practices outlined here, your driving 
needs to be improved. 

Safe Driving Practices 

1. Entering a through street or highway. 

As you start out on any trip you usually enter a through street or high- 
way from a driveway or minor side road. At such locations you can avoid 
trouble by slowing down enough to look for approaching cars from both 
directions. If there is a stop sign, stop completely before looking for 
approaching cars. 

It's up to you to give the right-of-way to all traffic on a through street 
or highway. Wait for a gap in traffic before entering a throughway. 

2. Turning corners. 

(a) To the right- -Before you turn to the right, move into the right-hand 
lane, check your mirror for traffic behind, and signal your intention of 
making a right turn, making sure that other drivers see and know what you're 
going to do. Slow down before making the turn. Just before turning, check 
traffic coming from your left. 

Turn the corner at a speed that will keep you on your own side of the 
street- -and in your own lane. After completing the turn, check your mirror. 
Get into the habit of checking your mirror after every turn. Keep your- 
self "in the know" as to traffic behind and how close it is to you. 

(b) To the left- -When you want to turn left, move into the center lane 
or the far left lane on one-way streets, check your mirror, and signal 
your intention of turning. Watch for a gap in the traffic coming from the 
opposite direction. Time your arrival at the turning point to take advan- 
tage of this gap. By proper timing you can often avoid a complete stop. 

Slow down before starting the turn. Just before turning, check traffic 
coming from your right. 

Turn the corner at a speed that will keep you on your own side of the 
street and in your own lane. Avoid cutting corners when making left turns. 
After completing the turn, check your mirror again. 



26 



Medical News Letter, Vol. 25, No. 3 



(c) U-turning- If you have to reverse direction, try to do so in an off- 
street space. Next best is to go around the block. If you make a U -turn, 
stop first near the right-hand curb and look carefully in all directions for 
gaps in traffic. If the street is too narrow to permit a U-turn, stop and 
back into a driveway on the right-hand side of the street. It's always 
better to back off the street and head out into traffic than to head into a 
driveway and back out into traffic. 

3. Stopping. 

When driving in high gear, use your brakes first. After slowing down 
to about 10 miles per hour, press down the clutch pedal. Leave the gear 
shift lever alone until your car has stopped. 

By "playing" the traffic lights and watching what's happening ahead, 
you can avoid many stops every day. Keep your attention on developments 
ahead, and plan your speed so that you will not have to stop often. You'll 
save car, brakes, and nerves by so doing. By all means, avoid quick 
stops, especially when the road surface is slippery. 

4. Parking. 

When parking on the street, be sure you are far enough away from 
driveways, fireplugs, corners, and alleys. If you have to back into a 
parking space, do it slowly and be sure the way is clear behind you. Back- 
ing accidents are of the most common types of accidents with trucks. If 
you park on a hill, set the front wheels against the curb so that your vehi- 
cle cannot roll away by itself. 

5. Sharing the road. 

You can avoid a lot of trouble in driving by sharing the road with other 
vehicles. Be aware of the position of your own vehicle in relation to other 
traffic, especially in streets without marked lanes. Avoid crowding other 
vehicles at any time. Check your mirror frequently so that you know when 
a car behind you is about to do something which will affect you. 

The vehicle you drive may be marked U. S. N. ; if not, then because of 
your uniform other drivers know whom you represent even if they don't 
know you personally. Share the road with others --and avoid trouble. 

6. Overtaking and passing. 

The common practice is to overtake and pass other vehicles on the 
left. Before you pass another vehicle, make sure you have enough room 
to complete the pass without interference from oncoming traffic. If there 
is enough time to pass, check behind to see whether someone else is about 
to pass you. 

After you have passed the vehicle, check your mirror before pulling 
over to the right-hand lane. You should be far enough ahead of the vehicle 



Medical News Letter, Vol. 25, No. 3 



27 



to see the corner of it in your mirror before returning to your proper 
lane. Remember, there's a penalty for "clipping". 

In the daytime, sound your horn as you pull out to pass. At night, 
flick your headlights twice as additional warning to the driver ahead 
that you intend to pass him. If you're the one that's being passed, you 
should depress your headlight beam to signal the driver passing you that 
he has cleared and can safely return to the right lane- -and of course to 
reduce the glare in his rear view mirror. 

In cities it's customary to pass other vehicles on the right if they 
are slowing down or are stopped to turn left at an intersection. On one- 
way streets, pass other vehicles on either the right or left side, after 
first making sure no one from behind wants to pass you and that the driver 
ahead knows you're intending to pass him. 

7. Right-of-way at intersection s. 

You hav« heard numerous rules about who has the right-of-way at 
intersections. Regardless of where you drive, your jobis to drive 
so that you neither hit nor get hit by another vehicle at any intersection. 

Even though the law says that you should yield the right-of-way to 
vehicles approaching from your right, don't forget that the best practice 
in checking an intersection for cross traffic is to look first to the left and 
then to the right and then give the right-of-way to any fool who wants it ! I ! 

Collisions are not avoided by drivers who try to apply the fine points 
of right-of-way rules after entering an intersection. If ytiU can't stop in 
time, the other fellow may not be able to stop either. Depend on yourself, 
not the other fellow, to avoid collisions at intersections. 

8. Keeping far enough behin d other vehicles. 

The frequency of rear-end "chain-type" collisions, where each of 
several vehicles in line plows into the rear of the one ahead, shows that 
many drivers follow too closely. Regardless of what the driver ahead 
may do, it's your job to be able to stop without crashing into the rear 
end of his vehicle. 

The best way to avoid rear-enders is to stay behind the vehicle ahead 
a distance equal in feet to twice your speedometer reading in miles per 
hour. For example- -at 20 miles per hour, follow no closer than 40 feet; 
at 30 miles per hour, the following distance should be not less than 60 
feet. Figure out the minimum distance for other speeds. 

9. Night driving. 

Lack of clear visibility makes your job more difficult at night--as it 
does for all drivers. You can compensate for this condition by adjusting 
your speed and following distances to what you can actually see. 



28 



Medical News Letter, Vol. 25, No. 3 



Modern sealed-beam headlights do a good job of illuminating roadway 
conditions ahead for approximately 200 feet. Traveling at 50 miles per 
hour you need more than 200 feet to bring your car to a complete stop. 
Exceeding 50 miles per hour at night means "over-driving" your head- 
lights. 

When meeting other cars at night, depress your headlight beam until 
you have passed by the other vehicle. If the other driver does not de- 
press his headlights for you, don't smash him in the eyes with your upper 
beam, because, in effect, you've got two blind men driving towards each 
other then. Take care of yourself by realizing that you will not see con- 
ditions ahead quite as clearly for several seconds afterward, until you 
are over the effects of glare from his headlights. Also, depress your 
headlights when following another vehicle. It will reduce the reflection 
the driver ahead gets from his mirrors. 

Headlights have still other uses. Professional drivers use them to 
signal each other as they meet on roads. One blink is a friendly greeting; 
two means trouble ahead, such as a traffic cop, minor accident, a detour, 
et cetera; three or more blinks of the headlights mean serious trouble 
ahead, such as a major accident, children or animals on the road, a 
bridge out, et cetera. The driver so warned regulates his speed and alert- 
ness accordingly. If a Navy driver began using these signals to help his 
buddies as they meet on the road, many accidents could be averted. 

10. Hazar dous driving conditions . 

When unusual conditions arise, follow these sound practices and avoid 
trouble : 

(a) If you have to park along the highway for an emergency, pull off the 
pavement if at all possible. Otherwise, use flags or flares to warn other 
drivers that your vehicle is parked on the road. Carry a couple of empty 
quart milk cartons in your trunk (the waxed type); they make excellent 
flares, 

(b) To avoid skids in starting, turning, or stopping on slippery road 
surfaces, make easy starts and stops, and slow down before turning. 

(c) When fog or smoke cuts down visibility, reduce your speed and 
keep it reduced until you are in the clear again. 

(d) If your right wheels slip off the pavement, ride the shoulder until 
you can slow down. Then pick a spot where the shoulder level is even 
with the pavement level to swing back onto the paved surface. 

(e) Rough roads and gravel roads call for slower speeds. Your tires 
have less traction on such roads, which means you have to start, turn, 
and stop more slowly. 

11. Pedest rians and bike riders. 

Take it easy when you see people walking along the road, and when 
you see children riding bicycles. They can get in your way unexpectedly, 



Medical News Letter, Vol. 25, No. 3 



29 



and often they cannot move out of your way fast enough. You have to 
judge each situation for yourself; but be sure to allow an extra margin 
for the mistakes of pedestrians and bike riders. 

12. Competent driving. 

When you drive like a real expert, people can see the difference. 
Among the ways they spot you as an expert driver are the following: 

(a) You have a business-like and alert posture at the wheel. 

(b) You handle the car controls easily and smoothly. 

(c) You use the brakes infrequently because you "play" the traffic 
lights, keep a safe distance from the vehicle ahead, and act in advance 
on all the clues that show you what others are likely to do. 

(d) You are constantly aware of the position of your own car in rela- 
tion to other traffic, especially on streets without marked lanes. You 
check your mirrors frequently so that you know how things are going 
behind you. Other drivers rarely blow their horns at you because you 
stay where you belong. 

(e) You time your arrival at intersections and other locations where 
you cross or merge with other traffic so as to fit in where the traffic gaps 
occur. This makes it easy and smooth for you and others to keep moving. 

(f) You position your vehicle in the correct lane in advance of all right 
and left turns. Doing this along with signaling for your turns keeps every- 
one informed as to what you intend to do. 

(g) You stay far enough behind other vehicles at all times. 

(h) You never make emergency stops {an emergency stop is the next 
thing to a collision, and indicates you were not completely "on the ball"). 

(i) Your vehicle, month in and month out, continues to look like one 
that is driven by an expert. 

13. In closing, although time and money do not allow for a great deal of 
driver improvement training, the men and women of the Navy can accom- 
plish self-improvement in highway safety by applying the rules just listed. 
Remember- -in or out of your Navy uniform, you are convinced that only 
one thing saves--SAFE DRIVING PRACTICES. (Naval Training Bulletin, 
Nov. , 1954) 

$ # sje $ $ $ 

Medical Care of Atomic Casualties 

The Army Medical Corps is presenting courses on the "Medical 
Care of Atomic Casualties" at the Army Medical Service Graduate School, 
Walter Reed Army Medical Center, Washington, D. C. The Army is plan- 
ning to have eventually all its medical officers attend this course, the early 1 
courses being given to the senior medical officers. Five quotas have been 



30 



Medical News Letter, Vol. 25, No. 3 



allotted to the Medical Department of the Navy and the Bureau of Medicine 
and Surgery would like to have as many medical officers as possible, 
especially those in command or planning positions, take this course. 

All expenses incident to attending this course will be borne by the 
Bureau of Medicine and Surgery. 

The next course is scheduled for 7-16 March 1955, inclusive. 

Applications for this course should be addressed to: Bureau of Med- 
icine and Surgery, Attention: Training Division; and should be submitted 
in time to arrive at the Bureau by 18 February 1955. 

sfc ^fi sfr* ■■'flff 3^ 

Medical Deep Sea Diving and Submarine 
Medicine Technicians 

It is desired that all Medical Department officers advise Group X 
hospital corpsmen of the acute need for volunteers for training in Medical 
Deep Sea Diving and Submarine Medicine Technic. 

For Medical Deep Sea Diving, hospital corpsmen holding the ratings 
of HM1 and HM2 are eligible provided they meet the prerequisites outlined 
in the Catalog of Hospital Corps Schools and Courses. For those interested 
in this specialty a recent article published in the September-October 1954, 
Volume 5, Number 5 issue of the Medical Technicians Bulletin entitled, 
"The Corpsman Goes Deep Sea Diving" may be enlightening. 

For those interested in submarine medicine technic, the training is 
open to HMCs, HMCAs, HMls, and HM2s, who meet the prerequisites set 
forth in the Catalog of Hospital Corps Schools and Courses, with the excep- 
tion that the requirement of being a graduate of the advanced Hospital Corps 
School (Class B) is no longer required, and who meet the basic battery test 
score requirement for initial submarine training. Reference should also be 
made to BuPers Notice 1540 of 5 June 1953, which is Change No. 1 to 
BuPers Instruction 1540.2, in regard to basic battery test score require- 
ment. A change in the Catalog of Hospital Corps Schools and Courses will 
be forthcoming. (Hospital Corps T raining -BuMed) 

$ ife $ jje sje sjt 

Postgraduate Short Courses 

The Armed Forces Institute of Pathology will present the following 
postgraduate short courses during the periods indicated. 

Ophthalmic Pathology 21-25 March 1955 

This course is designed for the ophthalmologist and the general path- 
ologist. Material will be presented by lectures, demonstrations and the 



Medical News Letter, Vol, 25, No. 3 



31 



study of microscopic slides. Ten spaces have been reserved for the use 
of this Bureau. Interested medical officers should forward requests for 
attendance via official channels in time to reach BuMed prior to 15 Feb- 
ruary 1955. 

Travel and per diem orders chargeable against Bureau funds will be 
authorized those approved for attendance. Priority will be given requests 
from medical officers who are Board certified, Board qualified, or senior 
residents in Ophthalmology or Pathology. 

Application of Histochemistry to Pathology 2-4 May 1955 

This course is designed for medical officers who are Board certified, 
Board qualified, or well advanced in the study of Pathology. The material 
will be presented by lectures, laboratory demonstrations, and the study of 
microscopic slides. Five spaces have been reserved for the use of this 
Bureau. Interested medical officers should forward requests via official 
channels in time to reach BuMed prior to 1 April 1955. 

Travel and per diem orders chargeable against Bureau funds will be 
authorized those approved for attendance. Priority will be given requests 
from medical office-rs who are Board certified, Board qualified, or senior 
residents in Pathology. {ProfDiv, BuMed) 

****** 

BUMED NOTICE 7303 30 December 1954 

From: Chief, Bureau of Medicine and Surgery 

To: All Activities under Management Control of the Bureau of Medicine 
and Surgery 

Subj: Status of Allotment, NAVEXOS 3443; reporting of reservations on 

Ref: (a) Hospital Accounting Instructions, NavMed-P- 1296, Change 21 

This Notice invites attention to paragraph 45200. 5i of reference (a) requir- 
ing inclusion of information on allotment reservations in block 9 of the 
Status of Allotment Report, NAVEXOS 3443. 

# sfr # a|e $ $ 

SECNAV NOTICE 6300 5 January 1955 

From: The Secretary of the Navy 
To: Distribution List 



Subj: Navy and Marine Corps Cancer Education Program 



32 



Medical News Letter, Vol. 25, No. 3 



Encl: (l)U.S. Navy Cancer Education Program Kit 

This Notice institutes a basic education program on cancer control for all 
Navy and Marine Corps military, civilian, and dependent personnel. 

****** 

BUMED INSTRUCTION 6230.1 SUP 1 19 January 1955 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Immunization Certificate, DD Form 737 

Ref : (a) Chapter 22, Section VIII, Manual of the Medical Department, USN 
(b) BuMedlnst 6230.1 

(c} International Certificate of Vaccination of the World Health 
Organization, PHS-731 

This Instruction informs addressees that the United States Navy Immuniza- 
tion Record, NavMed 585, has been superseded by the Department of Defense 
Immunization Certificate, DD Form 737, and provides guidance in the use 
of the newly adopted form pending revision of references (a) and (b). 

****** 




PREVENTIVE MEDICINE SECTION 



Communicable Disease Control 

Occurrence of Influenza, July 1953 to June 1954 

Investigators and diagnostic laboratories located in universities, 
hospitals, and Federal and State agencies, including Army, Navy, and 
Air Force installations, have collaborated since 1948 in reporting the 
occurrence of specifically diagnosed influenza as a part of the World 
Health Organization Influenza Study Program in the United States. These 
communications are summarized weekly in the Communicable Disease 
Summary of the National Office of Vital Statistics, Public Health Service, 
and are also distributed to health officials and interested research workers 



Medical News Letter, Vol. 25, No. 3 



33 



in the United States and other countries, and to the headquarters of the 
World Health Organization in Geneva. The program, operating on a world- 
wide basis, also facilitates the exchange of newly isolated strains of influ- 
enza virus for study purposes. 

During the period covered by this report, July 1, 1953, to June 30, 
1954, the incidence of influenza in the United States was the lowest in 4 
years. It was characterized by the absence of outbreaks caused by influ- 
enza A virus, although infections with influenza B and influenza C were 
recorded. 

The failure to identify epidemic influenza A occurred in spite of 
extended epidemiological and laboratory studies by the military services 
and the Public Health Service, and in spite of close surveillance by State 
health departments and the Epidemic Intelligence Service of the Communica 
ble Disease Center, Public Health Service. During almost every month 
of the winter season, Army area laboratories reported a few instances of 
a significant increase in titer of serum antibodies against influenza A in 
the hemagglutination inhibition tests. However, no report of the isolation 
of influenza A virus in the United States was received at the WHO Influenza 
Information Center. 

Influenza B was diagnosed serologically in a number of high school 
students in Santa Clara County, Calif. , who had respiratory illnesses in 
the middle and latter part of January. In February, March, and April, 
localized outbreaks of influenza B were identified in other parts of Cal- 
ifornia. In late March and early April, a minor outbreak of influenza B 
occurred at a naval installation in Illinois. Strains of virus were recovered 
which appeared to differ from the Lee strain. Influenza B was also serolog 
cally confirmed in localized areas of Minnesota during March and April. 

Influenza C virus was recovered first in December 1953, at a naval 
installation in Illinois, and then sporadically during the remainder of the 
winter. It was also isolated from 4 members of 1 family and from 2 other 
individuals in Norfolk who had a respiratory illness in April. 

The mortality experience during the winter season gave no evidence 
of any increase as a result of influenza, as, according to the National Offic 
of Vital Statistics, is usually the case when an epidemic is prevalent. 

In other parts of the Western Hemisphere, influenza A was identified 
in two small outbreaks in Puerto Rico in March, and two isolated strains 
were found to be similar but not identical to A/FW/1/50 and A/FLW/1/52. 

In South Africa, during late May and June 1954, there was a sharp 
outbreak of influenza. Recovered strains examined at the World Health 
Influenza Center in London proved to be influenza A similar to the Liver- 
pool strain A/ England/ 1 / 5 1 . In Australia, influenza A was also prevalent 
during the same period. (Public Health Reports, Dec. , 1954; D.J. Davis, 
M. D. , influenza Information Center, WHO Influenza Study Program in the 
United States, National Institutes of Health, Public Health Service) 



34 



Medical News Letter, Vol. 25, No. 3 



Influenza Vaccines in Great Britain 

An announcement of influenza vaccine trials is made in the British 
Medical Journal, November 13, 1954, by the Medical Research Council 
Committee on Clinical Trials of Influenza Vaccine of the Ministry of 
Health. In this announcement, there is reference to a controlled study 
carried out in 13,000 civilian volunteers during the winter of 1952-1953. 
The vaccine contained equal proportions of FM-1 (USA 1947) and the Liver- 
pool (England 1951) strains of influenza A viruses. A 40% reduction in 
clinical illness was obtained in the vaccinated group (British Medical 
Journal of November 28, 1953, p 1173). 

Following favorable American reports on oil-adjuvant influenza 
vaccines (as a method of obtaining greater and more persistent antibody 
responses) trials of this type of vaccine have been carried out in several 
student groups since December 1953. These trials have apparently con- 
firmed earlier American reports as to the efficacy of the vaccine in pro- 
moting high antibody titers and as to its freedom from reactions. 

During the winter of 1954-1955, additional field trials will be carried 
out in 16,000 volunteers. Four vaccines are being used. Three vaccines- - 
one saline and two oil-adjuvant- -contain the England 1954 strain of influ- 
enza A. The fourth vaccine contains influenza virus B. 

The results of these tests will be awaited with interest because the 
compositions of the baccines are different from those being used in the 
Armed Forces this winter and since there is interest in the oil-adjuvant 
vaccines as a means of avoiding the annual vaccination against influenza 
which must be carried out with saline influenza vaccines. 

$ sjc * # * $ 

Tuberculosis Control 

Photofluorographic Detection of Cardiovascular 
Disease in a General Hospital 

The importance of the chest survey photofluorogram in the discovery 
of pulmonary lesions is well recognized. Recently, this method has also 
been used to detect cardiovascular disease and, in this particular paper, 
in routine admissions to a general hospital. 

A study of this type has several inherent limitations, namely: (1) 
Cardiac patients with normal cardiac silhouettes will be overlooked. (2) 
There is a significant difference in interpretation, not only by equally 
skilled radiologists, but also by the same radiologist on successive days. 
(3) There is a wide variation in the degree of accuracy in detecting cardio- 
vascular disease because of the difference in the individual criteria of 



Medical News Letter, Vol. 25, No. 3 



35 



abnormality. (4) The frequency of abnormal cardiovascular silhouette 
varies with the segment of population examined. 

This survey consisted of 6439 adults, 709 of whom were suspected 
of having a cardiovascular abnormality on the basis of the admission 
photofluorogram. Follow-up study of 595 revealed 497 (83%) to have 
cardiovascular disease. Of 416 (69%) patients evaluated for prior know- 
ledge of cardiovascular disease, 196 (47%) were unaware of the presence 
of such disease. This is consistent with the results of other studies. 

The frequency of cardiovascular disease in the population studied is 
much higher than that reported in the usual mass survey. This is primari- 
ly due to the facts that the average age of the patients was greater, and that 
a significant number of patients were hospitalized because of cardiovascular 
disease. 

The surgical group consisted of 3305 adults. Five hundred and twelve 
were suspected of having abnormal cardiovascular silhouette. In spite of 
the fact that the group is biased by selection, which is unavoidable because 
the surgeon does a certain amount of screening, 368 out of the 437 indi- 
viduals who were followed up had verified cardiovascular disease. Because 
the findings were called to the attention of the surgeons, many of the patients 
benefited. In a few cases the complete cardiovascular study led to a correct 
diagnosis of the patient's illness. 

The medical group was relatively small because it was limited to 
ambulatory patients, and many patients admitted on the service were quite 
ill. As a result, many with known cardiac disease were not included in 
this study. The group totalled 477; 156 had abnormal photofluorograms. 
One hundred and fifty-four were followed, and 121 of these had cardiovas- 
cular disease. The frequency of abnormal photofluorograms is probably 
a reflection of the older age of the medical patients. 

Of the 2657 women in the young obstetrical group, 41 were suspected 
of having a cardiac lesion, which is in the range that one might expect in 
young adults selected at random. 

No cardiovascular abnormalities were discovered on the lateral 
photofluorogram which was taken in addition to the P-A film on all patients 
except the very obese and pre natal. The lateral view was of value in 
appraising some of the factors such as body build, scoliosis, and pectus 
excavatum which increased the number of false positive diagnoses. In 
essence, the lateral projection helped to increase the accuracy of the read- 
ing but did not increase the absolute yield. (New England J. Med. , 2 Dec. , 
1954; H. D. Batt, J. M. Allen, F. H. Treder, and R. Shapiro, New Haven, 
Conn. ) 

****** 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, June 23, 1952. 



36 



Medical News Letter, Vol. 25, No. 3 



Insect and Rodent Control 

Attack on Insect and Rodent Vectors at 
Preventive Medicine Unit No. One 

The organized attack on insect enemies in the United States began 
in 1854, just 100 years ago last year. Battle lines were drawn and the 
first offensive sorties were carried out in that historic year by 
Townend Glover, working for the Federal Government, and Asa Fitch, 
working for New York State. Following the trail blazed by these pioneers, 
were C. V. Riley and L.O.Howard, both giants in the earlier days of profes- 
sional entomology. The latter was one of the earliest and most dynamic 
workers in medical entomology in America. The succeeding procession 
of stalwarts goes on into our own day. From simple beginnings, great 
strides have been made in the unending struggle of man against the in- 
sect world. Last year, as professional entomology celebrated its cen- 
tennial, some 4500 men and women entomologists in the United States 
had taken up the challenge, and today they are continuing the attack in 
one way or another. 

The Navy has not been unmindful of its responsibilities in this epic 
struggle and since the beginning of World War II has placed increasing 
emphasis on combat operational readiness against these six-legged ene- 
mies- particularly the vectors of human disease and misery. One of the 
earlier signal efforts along these lines was the establishment of malaria 
and other epidemic disease control units. 

The U.S. Navy Malaria and Mosquito Control Unit No. 1 was com- 
missioned on 1 July 1949, at the U.S. Naval Air Station, Jacksonville, 
Florida. On 12 November 1952, the Unit was redesignated U.S. Navy 
Preventive Medicine Unit No. 1. It is under the military command and 
coordination control of the Commandant, Sixth Naval District, and under 
the management and technical control of the Bureau of Medicine and Sur- 
gery. The Unit's strategic location at the Naval Air Station, where 
air support is readily available, greatly enhances its value and capacity 
for immediate service mobility. 

The services available from Preventive Medicine Unit No. 1 are 
limited to the vector control phases of the naval preventive medicine 
program. This Unit exists primarily to supplement the efforts of local 
medical activities to recognize and define vector problems of naval im- 
portance and to devise means of prevention or control. Here the term 
"vector" is used in the broad sense, as defined by SecNav Instruction 
5420.17, to include all organisms which: play a significant role in the 
transmission of disease to man; act as intermediate hosts or reservoirs 



Medical News Letter, Vol. 25, No. 3 



37 



of disease; present problems of sanitary or hygienic significance; or other- 
wise affect the health and efficiency of personnel. The Unit provides the 
following specific services to the Naval activities of the Sixth Naval Dis- 
trict: 

1. Technical consultative assistance with problems relating to 
vector prevention and control. 

2. Study of disease vectors and supplementation of local control 
services where indicated and feasible; recommendations and technical 
assistance for special area-wide services for vector control. 

3. Insecticides suitable for aerial and ground application for the 
control of mosquitoes, sandflies, and other vectors to activities that can 
justify the need for them. 

4. Nonstandard and special-use insecticides where their need is 
indicated and can be justified. 

5. Specialized control and survey equipment on a custody basis 
where such equipment is needed and can not be procured otherwise. 

6. Maintenance service on specialized dispersal equipment. This 
includes modernization of equipment and the replacement of worn parts. 

7. Aerial spray services for naval activities near Jacksonville where 
the need is justified. 

8. Vector survey, detection, forecasting, and laboratory identifica- 
tion services. 

9. Current literature and guides relating to arthropod and rodent 
control recommendationa and technics. 

10. Basic advanced, and refresher training in pest and vector pre- 
vention and control for military and civilian per sonnel responsible for 
pest control programs at naval activities and for reserve Medical Depart- 
ment personnel. This includes indoctrination of personnel in the safe 
handling and use of pesticides and in specific methods of disease vector 
control. 

11. Periodic inspection service, in cooperation with the District 
Public Works entomologist, for all station pest control programs in the 
Sixth Naval District, and submission of reports as necessary. 

12. Field service testing and development when authorized. 

13. Liaison with governmental and other agencies as necessary for 
accomplishment' of the Unit's mission. 

Preventive Medicine Unit No. 1 is under the direction of an Officer- 
in-Charge who is a Medical Service Corps officer. Four departments 
make up the internal structure of the organization. These include the 
Administration, the Operations, the Testing and Development, and the 
Training Departments, headed up by MSC officers and a Civil Service 
entomologist. Seven enlisted personnel are included in the complement 
of the Unit, six of whom are hospital corpsmen, the other a Chief machin- 
ist Mate. A machinist mate billet was established in order to support the 



38 



Medical News Letter, Vol. 25, No. 3 



equipment maintenance and overhaul service. This billet has also been 
valuable for training operators of spray equipment in proper maintenance 
and operating technics. 

In the early years of the Unit's existence, an extensive program was 
established for testing aerial insecticide dispersal devices, developed by 
the Bureau of Aeronautics for use on military combat-type aircraft. Much 
of this work was conducted in conjunction with the Army Chemical Corps. 
The Unit pioneered in the development of automatic aircraft disinfe station 
equipment. The Officer-in-Charge was responsible for devising a new 
spray system, whereby aircraft traveling outside of, or entering, the 
continental limits of the United States could be automatically treated with 
insecticide to eliminate the spread of disease -bearing or other noxious 
insects. Previously, hand-applied aerosols had been used exclusively. 
Several modifications were required in the automatic disinf estation equip- 
ment; it is still in the testing phase. This project was moved to the West 
Coast in 1952. 

In 1952, a project was established for the purpose of converting into 
insecticide dispersal equipment Todd Type E Smoke Generators, which had 
been installed on the fantails of destroyers for the purpose of laying passive 
defense smoke screens. These smoke generators were removed from ships 
which had been placed in the "mothball fleet. " 

An excellent multipurpose insecticide dispersing machine resulted 
from this project. The contrivance, now known as the "MIDA", can be used 
for residual spraying, misting, and wet or dry dusting. Thirty-four of these 
machines have been distributed to naval installations in the United States 
and foreign shore stations. The conversion plans and specifications were 
sent to 38 activities. 

Another machine which was converted from the smoke generator by 
the Testing and Development Department can be used in termite control 
operations. One machine of this type has been successfully used over a 
period of 2 years for both soil poisoning and surface treatments. As a 
result sixteen sets of the conversion plans and five unconverted smoke 
generators were sent to naval activities requesting them. 

The Operations Department was not idle during this time. Instance 
the Kansas City flood of 1951. In July of that year members of Preventive 
Medicine Unit No. 1 were sent to the Kansas City disaster area to assist 
in emergency insect and rodent control measures. Within 24 hours after 
the Unit received a dispatch from the Bureau of Medicine and Surgery, 
two planes loaded with insecticide spray equipment and personnel were 
under way. Insect control was a necessity as the flood waters rose and 
inundated the stockyard and other areas, drowning many animals and caus- 
ing widespread organic decomposition. These sources produced enormous 
fly populations. Upon arrival, the local health authorities and U. S. Public 
Health Service officials were contacted. A cooperative fly-control program 



Medical News Letter, Vol. 25, No. 3 



39 



was planned and put into effect. Daily continuous spraying was carried out 
for a period of 2 weeks in the flooded sections of the city and adjacent are?.s. 

The foregoing example typifies the mobile and flexible nature of this 
Unit which is on call 24 hours a day. The Operations Department has been 
called upon frequently to conduct field inspections, surveys, and investiga- 
tions of vector problems, both within and outside the Sixth Naval District. 
In this respect, it functions, so to speak, as a sort of mobile vector-combat- 
intelligence service. 

The Training Department as such is newly conceived in name only for 
the Unit has long exerted serious efforts in the direction of this important 
aspect of vector control operations. A training program for the U. S. Naval 
Reserve Medical Department personnel has been in progress at the Unit 
since November 1948. At present, classes convene the third Wednesday of 
each month throughout the year. Medical Corps, Medical Service Corps, 
and Hospital Corps personnel are eligible to attend the 14-day course which 
includes lectures, demonstrations, and field work with emphasis placed on 
all phases of arthropod and rodent vector recognition and control. To date 
226 Rese rvists have taken advantage of this opportunity for serving on 
annual training duty with the Unit. The need for, and interest in, such 
training duty are borne out by the fact that the number of trainees increased 
from 26 in 1949, the first full year of operation, to more than 58 in 1954. 

In addition to the Reserve program, training services offered by the 
Unit are many and varied. For example, District pest control program 
personnel, both military and civilian, may receive on-the-job training in 
pest and vector procedures, and indoctrination in the safe handling and use 
of pesticides. Decentralized training is also available on request at all 
stations. Through these various training media, the Unit hopes to effect 
more rational, effective, safe and economical vector and pest control 
throughout the District. Although the saving and conservation in material 
and human resources now being realized are extensive, even greater saving 
is clearly envisaged through future emphasis on training. 

The contribution of this Unit in the over-all health, welfare, and 
comfort of the Navy in the Sixth Naval District and elsewhere is of course 
an intangible value. Perhaps its worth is best attested to by the officers 
and men of the many activities who continue to look to the Unit for assit- 
ance and support year in and year out in the solution of their problems 
and in their attack on insects and rodents. 

General Sanitation 

Food Infection Possible in Synthetic -Cream -Fille d Pastry 

The Oakland City and California State Health Departments have recent- 
ly reported studies of cream-filled pastries made with new "synthetic" 



40 



Medical News Letter, Vol. 25, No. 3 



filling. It had been alleged that the synthetic substitutes for standard 
cream filling of pies and pastries would support bacterial growth poorly. 
However, a few initial studies made by the State Health Department Labor- 
atory on pies from the shelves of distributors have shown very high total 
bacterial counts with 1000 to 180,000 potentially dangerous staphylococci 
per gram. In nearly every instance these staphylococci gave all the cul- 
tural reactions consistent with the pathogenic and/or toxigenic strains of 
staphylococci, i. e. , those strains associated with bacterial food intoxica- 
tion. 

As a result, the State of California has determined that the same 
strict rules for refrigeration of cream -filled pastries should be applied 
equally to those made with so-called synthetic cream filling. The ingred- 
ients of these mixtures, while omitting cream, do include dry skim milk, 
egg white, starch, sugar, agar, meringue powder, and shortening, and 
should support bacterial growth. 

These research studies underscore the necessity for constant refrig- 
eration of all types of cream -filled pastry during the interim between baking 
and serving. (Environmental Sanitation Technician Course, U.S. Naval 
Hospital, Oakland, California) 

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